Bright & Quirky Child Summit 2021: Tame The Overwhelm was a 5-day free online summit which aimed to help twice exceptional (2e) children - gifted children with ADHD, autism, learning differences like dyslexia, anxiety and/or depression. The conference featured 28 educators and psychologists who shared science-informed actionable strategies that promote social, emotional, and academic thriving even in tough times. The summit was hosted by Debbie Steinberg Kuntz, a licensed marriage and family therapist as well as the Founder of Bright & Quirky. Day 2 focused on motivating kids and balancing tech.
Understanding High IQ Kids With ADHD and Co-Occurring Diagnoses - Thomas E. Brown, PhD
Thomas E. Brown earned his PhD in Clinical Psychology at Yale University and then served on the clinical faculty of the Dept. of Psychiatry at Yale School of Medicine for 20 years while operating a clinic in Connecticut for children and adults with ADHD and related problems. In May, 2017 he relocated to California where he opened his Brown Clinic for Attention and Related Disorders in Manhattan Beach, California. He has taught continuing medical education courses on ADHD for the American Psychiatric Association for the past 20 years and has given lectures and workshops in hospitals, medical schools, universities and for professional and advocacy groups throughout the U.S. and in more than 40 other countries. He has published 30 articles in professional journals and 5 books on ADHD. His most recent books are Smart, but Stuck: Emotions in Teens and Adults with ADHD, and Outside the Box: Rethinking ADD/ADHD in Children and Adults-A Practical Guide.
Dr. Brown noted that our understanding of attention deficit hyperactivity disorder (ADHD) has increased a lot compared to the past. We now know that ADHD is not just seen in young boys, but can be present across gender and age. We also have stopped defining attention in a narrow sense, such as focusing on a whiteboard or book. Instead, we now talk about executive functions, which is the broader ability to manage ourselves and the information we have to pay attention to when we focus in daily life. For example, when focusing on driving safely, we have to pay attention to multiple types of information – notice the rearview mirror and sideview mirror, avoid hitting the cars and pedestrians in front of us, shift between the accelerator and brake as the traffic light changes colour, ignore interesting store window displays, remember the list of groceries we need to buy when we reach the grocery store, etc. The infrastructure which supports the executive functions, the frontal lobe, is one of the slowest parts of the brain to develop. It is typically not fully mature until about 18 to 20 years old, which is why most countries set a minimum driving age of around 18 years old. In bright and quirky children, parts of their brain might be extremely sharp and advanced, whereas their self-management system might be lagging.
Dr. Brown grouped executive functions into 6 clusters. These are different types of cognitive functions rather than different parts of the brain. Nonetheless, they interact in dynamic ways, and almost everything we do involves multiple parts of the model. Although everybody has trouble with these executive functions sometimes, people with ADHD have a lot more trouble with them. ADHD is not an all-or-nothing phenomenon like pregnancy, in which someone is either pregnant or not pregnant, and cannot be somewhere in between. Rather, ADHD is more like depression, in which everybody experiences occasional unhappy moments, but individuals diagnosed with clinical depression have persistent depressive symptoms that affect daily functioning.
Activation: Organising, prioritising, and activating to work.
E.g. Difficulties organising stuff in their backpack or notebook reasonably well compared to other children of the same age.
E.g. Difficulties getting started with work, with a tendency to procrastinate on an assignment till the last minute when it is due.
Focus: Focusing, sustaining, and shifting attention to tasks.
E.g. Easily distracted from tasks, such as by classmates’ activities and conversations, the view outside the window, or their own thoughts. They have difficulties separating the signal from the noise.
Every person with ADHD has several tasks they can be naturally hyperfocused and engaged in, such as playing a particular sport, creating artwork, building structures with Lego blocks, or watching specific television shows. However, people with ADHD have difficulties focusing on tasks they are not interested in. While parents should encourage them to participate in activities involving their strengths and interests, parents also have to help them learn how to focus even in activities that they are not interested in, because there will surely be such activities in the course of their education and work.
Effort: Regulating alertness, sustaining effort, and processing speed.
E.g. Difficulties staying awake if they have to sit still for long periods of time such as to listen, read, or do paperwork. This is usually because of insufficient or poor quality sleep, either because they are unable to fall asleep due to an overactive mind, or because they stay up late doing things they are interested in such as screen time activities.
E.g. Able to do short-term tasks but have trouble with long-term projects, so they usually rush a long-term project without caring about quality or set it aside till it becomes more of an emergency. A track team runner with ADHD described her mind as being a great sprinter but a lousy distance runner.
E.g. Have a lot of good ideas but take a long time to get ideas down on paper for assignments such as long essays or book reports.
It is unclear why many gifted children have low processing speed. Although they can think fast and fine, they usually struggle to work with information and communicate their ideas to others, particularly in written expression.
Emotion: Managing frustration and modulating emotions.
E.g. Get angry over seemingly minor issues.
E.g. Sensitive to and easily hurt by others’ criticism, lack of attention, or unexpected responses.
E.g. Worry a lot about how things can go wrong in various ‘what-if’ scenarios.
Although emotion regulation is not in the diagnostic criteria for ADHD, many people with ADHD often have trouble managing their emotions.
Memory: Utilising working memory and access recall.
E.g. Unable to recall what happened minutes ago.
E.g. Unable to hold a telephone number in their head if they cannot write it down, possibly transposing digits.
E.g. Unable to retrieve information they studied during tests.
People with ADHD usually do not have problems with long-term memory. Instead, they have problems with short-term working memory and with retrieving information when they need it.
Action: Monitoring and self-regulating action.
E.g. Hyperactive behaviour such as constantly talking or bouncing legs.
E.g. Impulsive behaviour such as speaking before thinking through the consequences.
General restlessness often decreases by middle adolescence, which might lead to the mistaken belief that the child’s ADHD has disappeared. However, there are probably still impairments in other executive functions.
In his book ‘Outside the Box: Rethinking ADD/ADHD in Children and Adults-A Practical Guide’, Dr. Brown discussed how ADHD often co-occurs with other diagnoses. ADHD comorbidities are not due to some people being particularly unlucky. Instead, it is due to issues with how some people’s brain operates. As an analogy, ADHD is like a malfunctioning computer operating system. If a Microsoft PowerPoint programme goes down, it messes up the ability to work with presentation slides, but does not affect other software programmes like Microsoft Excel. On the other hand, if the operating system of a computer goes down, it messes up all of the computer programmes.
Base rate for anxiety is 5% in the non-ADHD population but 35% in the ADHD population
Base rate for learning disabilities is 5.3% in the non-ADHD population but 46% in the ADHD population
Base rate for conduct disorder is 1.8% in the non-ADHD population but 27% in the ADHD population
Base rate for autism spectrum disorder (ASD) is 0.6% in the non-ADHD population but 6% in ADHD population
Dr. Brown lamented that high IQ individuals with ADHD are often the most delayed in having their problems recognised and in receiving support. They may be able to do well in elementary school and middle school, but start to flunk in high school and university as the amount of structure and scaffolding is reduced. Parents and teachers often focus on their accomplishments and expect them to be able to perform just as well in other areas. Furthermore, parents and teachers see that they can focus, be productive, and excel in a few specific areas they are interested in, but cannot do the same in other academic areas. Thus, parents and teachers often mistakenly assume they are lazy, not trying hard enough or lacking willpower. This can cause twice exceptional children to beat themselves up.
Most clinicians still work with the old view of ADHD, and have little training in understanding the complexities of ADHD. As a result, clinicians often make a diagnosis based on the most obvious symptoms, not questioning or seeing that there may be other issues interacting and going on at the same time. The diagnosis that is made may be true, but may just be the tip of the iceberg. For example, in a Harvard study examining 107 youth with ASD, it was found that 76% of them also met the diagnostic criteria for ADHD. Yet, 41% of the ASD youth with ADHD failed to receive appropriate ADHD treatment.
It is important for parents to go the right evaluator with the appropriate training and experience, who understands that twice exceptional children have both remarkable strengths and struggles with executive functions or other issues. As such clinicians are hard to find, parents may have to speak to parents of other children dealing with similar circumstances.
As explained in his article for ADDitude magazine on the building blocks of a good ADHD diagnosis, Dr. Brown is not a fan of neuropsychological test batteries. Apart from being time-consuming and costly, they give a picture of how the child is functioning only for specific tests and only during the short period of time that the tests are being administered. Likewise, SPECT brain scans are an interesting research tool but does not provide an adequate way of assessing ADHD. Instead, he advocates an ADHD assessment that listens to the child and evaluates how the child functions day-by-day in a range of age-appropriate activities.
Think about how the child’s day flows. Does the child have a particularly challenging time, such as morning routine or homework time?
Think about how the child performs in different classroom settings. Does the child have more trouble with specific teachers or subjects?
Clinicians should conduct careful evaluation, looking at the whole picture of the child’s strengths and weaknesses in daily life. Then, clinicians should prioritise the challenge areas to work on based on how much they are getting in the way. Parents should encourage their child to build on their talents and passions, but this specialisation in strengths should not be done to the extent that they neglect working on their weaknesses. Instead, parents should also help the child recognise the unpleasant reality that school and work requires a diversity of skills, and assist the child in find ways to cope with aspects they find more difficult. For example, the child may love and excel in writing poetry and essays, but also has to learn to do basic math. The child may need additional help, either from parents, coaches, or private tutors.
Sometimes, a child with high IQ and complex ADHD may refuse to accept help. Despite wanting to do well, the child may feel ashamed and frustrated, as they excel in certain areas yet seemingly fail in other areas. Parents and clinicians can adopt an empathic approach, seeking to understand the child’s emotions. Moreover, if parents encourage the child to try out the first appointment just once, and if the professional is skilled and able to build rapport, the child often finds that accepting help can be nice and beneficial. Besides being empathic and encouraging, parents have to be clear that the child’s occupation in this point in life is to be a student. The child is therefore responsible to put in the effort to successfully get their school work done and develop their challenge areas. Parents can also consider providing reinforcers such as access to playing computer games.
Dr. Brown explained that ADHD is essentially a biochemical problem within the brain. Furthermore, it is highly genetic. ADHD is inherited; a child with ADHD is likely to also have a relative diagnosed with ADHD. The heritability index is a scale running from 0 to 1 that rates how much of a role genes play in a particular trait. The heritability index of ADHD is 0.74 based on 37 twin studies.
Dr. Brown emphasised that he does not believe in ADHD alternative treatments that lack robust scientific support, such as diet changes or computer-based cognitive training. Instead, he recommended carefully monitored medication as the most effective treatment for ADHD. He likened ADHD medicine to how eyeglasses are not a cure for myopia, but can improve one's vision when one has them on. Studies show that 70% to 80% of children with ADHD show improvements when given medicine, which are quite good odds. The two main types of ADHD stimulant medicines are methylphenidates, such as Ritalin, and amphetamines, such as Adderall and Vyvanse.
The caveat is that the medicine must be carefully prescribed for the particular child. It is critical for the clinician to fine-tune the medicine type, dosage, and timing to suit the child’s needs in order for the medicine to work. Unlike most other medicines, the prescribed dose of ADHD stimulant medicines does not go by the child’s age, weight, or severity of symptoms. Instead, it goes by how sensitive the child’s body is to a particular medicine. Clinicians should start with giving a small dose, then increase the dose gradually, looking for the sweet spot between too little and too much. If the dose is too little, it will be ineffective. If the medicine type is wrong or the dose is too much, the child might experience problems during the time the medicine is active, such as becoming jittery, becoming cranky, or having blunted emotions with a loss of the sparkle in personality. For some people, the medicine may work with no side effects during the time the medicine is active, but may start to cause problems when the medicine wears off after school is over. This phenomenon is known as a rebound or crash, and usually lasts for a few hours. As a solution, the child may need a long-acting dose as a school pill, followed by a small short-acting dose as a homework pill. This will allow the child to experience a slower descending curve instead of a sudden drop-off. Nonetheless, careful planning and consideration must also be given to the child’s schedule. For example, the medicine should not be taken at a timing that it might disrupt their performance in extracurricular activities after school, spoil their appetite for dinner, or prevent them from falling asleep at bedtime.
Whether or not medicine alone is sufficient depends on what the specific person’s problems are. Some people with ADHD can do well with medicine alone. They know what they ought to be doing; they just have difficulties getting themselves to do it, and the medicine helps them with it. The medicine can sometimes also help with other co-occurring diagnoses such as mood disorders. On the other hand, some people with ADHD combine medicine with coaching in order to learn the skills they need, and the medicine makes them more available to learn.
Medicine is usually not prescribed to young preschoolers aged 3 to 5 years old, unless there are safety concerns associated with the ADHD, such as a hyperactive tendency to run around or get lost in dangerous spaces. Medicine is prescribed to older children, depending on how often and how much of a problem the ADHD is. Some children need medicine all the time to help with various aspects of their life like social and emotional functioning, whereas some children need medicine only for school and homework.
As with any kind of medicine, ADHD medicine can suddenly lose its effectiveness, though it is not common. If it happens, clinicians can consider adjusting the dose, prescribing a different medicine of the same type, or prescribing a different type of medicine altogether.
Dr. Brown shared that he has just finished writing a new book titled ‘ADHD and Asperger Syndrome in Smart Kids and Adults: Twelve Stories of Struggle, Support, and Treatment’. The book describes ADHD and Asperger Syndrome, followed by 12 case examples across different age groups. The book emerged from his observation that a sizeable number of children with ADHD also have ASD or Asperger Syndrome. Children with Asperger Syndrome tend be extremely bright in some areas, but have issues with understanding others’ intentions or predicting others’ reactions. Therefore, they may need additional support in developing empathy and theory of mind. Unfortunately, few clinicians are experienced in dealing with both ADHD and Asperger Syndrome. It is important for parents to find clinicians who can understand and appreciate both aspects. Otherwise, a child who has both conditions but is diagnosed and supported for only one condition may struggle with how they function in school and in social relationships.
Dr. Brown wrapped with a message that parents should not only appreciate and nurture their child’s strengths, but should also recognise their child’s needs, helping them develop the skills necessary to thrive in school and at work. He also suggested that parents listen to his 28-minute talk for understood.org explaining what ADHD is, which has accumulated more than 3 million views.
All blogposts on Bright & Quirky Child Summit 2021:
Day 1 Talk 4 A Quick, Shareable Overview of Twice Exceptional (2e) Kids - Dan Peters, PhD
Day 2 Talk 8 Understanding High IQ Kids With ADHD and Co-Occurring Diagnoses - Thomas E. Brown, PhD
Day 3 Talk 13 How to Know When It's Time to Change Schools or Homeschool - Colleen Kessler, MEd
Day 4 Talk 17 How to Help Bright Kids Avoid Autistic Burnout - Kieran Rose
Day 4 Talk 19 How Different Kinds of Minds Can Become Inventors and Engineers - Temple Grandin, PhD
Watch this space for more blogposts from the Bright & Quirky Child Summit 2021!